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Paediatric Surgery

 

PAEDIATRIC UROLOGY

 

THE PENIS AND FORESKIN

 

WHAT IS NORMAL?

  • At birth, most baby boys’ foreskins are attached to the glans. As part of normal development, the foreskin (prepuce) slowly detaches from the underlying glans.

o   By 16 years only 3% will still have adhesions present

o   Only very occasionally, persistent adhesions require surgical intervention

  • A non-retractile prepuce is normal in babies and toddlers

o   By 16 years only 1% will still have a non-retractile prepuce (‘physiological phimosis)

o   The prepuce should never be forcibly retracted

  • ‘Ballooning’ of the foreskin during urination is a normal phenomenon

o   This is not an indication for surgical intervention

  • Occasionally, smegma can build up under the prepuce, leading to palpable lumps, which can discharge

o   This is a normal condition, and is related to preputial adhesions still present

o   Most will resolve spontaneously and not require surgical intervention

 

BALANITIS

  • Mild inflammation of the tip of the prepuce is common.

o   This can be due to contact with soiled nappies, or alkaline soaps / bubble baths.

o   Usually resolves with simple measures, such as drying the tip, and occasionally a short course of mild topical steroids. Surgery is not indicated.

  • Inflammation of the glans +/- prepuce is called balanitis.

o   This can sometimes be caused by an infection.

  • Soak in a warm bath, preferably with the foreskin retracted.
  • Topical steroid lotions (e.g. 0.05% betamethasone) are indicated in persistent or recurrent balanitis.

 

  • REFER IF RECURRENT / SEVERE BALANITIS

o   As scarring of prepuce / glans may occur

o   Circumcision may be offered.

 

 

BALANITIS XEROTICA OBLITERANS (BXO)

  • Sclerosing condition of the prepuce

o   In severe cases involves glans and meatus.

o   Can progress to a thickened non-retractile prepuce (pathological phimosis).

  • Early detection can respond to topical steroids

 

  • REFER ALL SUSPECTED CASES OF BXO

o   If scarring is present, circumcision is commonly offered.

 

 

ACUTE BALANOPOSTHITIS

  • Rare condition involving a pyogenic infection of the preputial sac.

o   Treatment requires antibiotics +- topical steroids.

 

  • REFER ONCE INFECTION HAS RESOLVED

o   Prepuceplasty or circumcision may be warranted

 

 

 

 

CIRCUMCISION

 

Indications

            Absolute       BXO phimosis

                                    Recurrent UTIs / balanoposthitis

            Relative         Recurrent / severe balanitis

 

  • Religious belief is not an indication for circumcision.
  • All procedures are performed as a daycase under a general anaesthetic (with local anaesthetic infiltration).

 

Contraindications

Hypospadius

Epispadius

Buried penis

Ambiguous genitalia

 

Surgical alternatives

  • Frenuloplasty

o   Increases the length of the frenulum in those with isolated scarring

  • Prepuceplasty

o   In pubertal boys with healthy but non-retractile foreskins, that do not wish a circumcision.

 

 

 

 

 

 

UNDESCENDED TESTIS

 

  • All male term babies should have both testes lying within the scrotum.

o   Around 1.5-2% unfortunately do not.

  • ~30% of pre-term babies may have an undescended testis:

o   By 3 months testicular descent should have occurred.

  • After one year, normal testicular development can be irreversibly impaired.

 

  • Paediatric Undescended testes do not require ultrasound confirmation and can be referred to the surgeons as per the guidelines.

 

  • REFER ALL SUSPECTED CASES IMMEDIATELY

 

Risks from an undescended testis

  • Reduced fertility
  • Increased malignancy risk (slightly improved with orchidopexy)
  • Risk of torsion
  • Risk of hernia

 

 

RETRACTILE TESTIS

  • Some boys (normally 3 to 7 years) have a strong cremasteric reflex

o   The testes regularly retract into the inguinal canal.

  • The testes should be present in the scrotum for most of the time.

o   Check at bathtime.

  • Occasionally, this is related to a high scrotal position of the testis

o   ‘high retractile testis’

 

  • REFER THOSE WITH RECURRENT / HIGH RETRACTILE TESTES

o   Requires regular specialist assessment until it resolves.

 

ASCENDING TESTIS

  • Over time, some boys’ testes appear to ‘ascend’ from a normal scrotal position to lie within the inguinal canal.

 

  • REFER ANY SUSPECTED ASCENDING TESTES

 

 

ORCHIDOPEXY

  • Surgically bringing the testis into the scrotum.

Common indications

  • Palpable undescended testis
  • Persistently retractile testis
  • High retractile testis
  • Ascending testis

 

If the testis is impalpable in clinic, a referral on to Bristol Children’s Hospital may be indicated, as the testis is likely to be intra-abdominal.

 

 

HYDROCOELE

 

  • Up to 5% of babies have a hydrocoele (fluid around testis) at birth.

o   From failure of the processus vaginalis to close, allowing fluid to ‘communicate’ with the abdominal cavity.

o   Classically: swelling increases during day, and improves overnight.

o   Differential diagnosis of a patent processus vaginalis (ppv) includes: indirect hernia, hydrocele of the cord, and very rarely testicular tumour.

  • Most (~ 90%) communicating hydrocoeles resolve within a year.

 

  • REFER ANY SUSPECTED HYDROCOELE CASES

o   Mainly to exclude other causes of scrotal swelling

o   Very rarely an USS is performed if diagnosis uncertain

o   Surgical intervention, to drain the hydrocele and ligate the ppv, is commonly offered in those over two years old.

 

 

PAEDIATRIC SURGERY

 

INGUINAL HERNIAS

 

Should be referred on the basis of parental history or examination findings

 

Operation is indicated within 6 weeks regardless of age of child

 

 

 

UMBILICAL HERNIAS

  • Very common in first year (10% of infants)
  • Most resolve spontaneously (85% of hernias resolve by age 1)
  • Strangulation/obstruction/pain very rare
  • No need for review unless skin over hernia threatened
  • Not usually repaired until age 4 at earliest